Carpal Therapist
Client Center
Pain Profile Form Submission
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Carpal Therapist Client Pain Profile
Patient Name:
Date:
Email:
The answers to your questions below will help Dr. Walker understand your unique condition helping to ensure your success.
Enter which limb you are profiling.
(Left or Right)
If both limbs are affected, you must submit a separate form for each limb.
SECTION ONE: Pain Quality
Each of the words in the left column describes a quality or characteristic that pain can have. For each pain quality in the left column, check the number in the right column that describes how much of that specific quality your pain has. Please rate every pain quality and select only one descriptor.
1) THROBBING
0 = None
1 = Mild
2 = Moderate
3 = Severe
2) SHOOTING
0 = None
1 = Mild
2 = Moderate
3 = Severe
3) STABBING
0 = None
1 = Mild
2 = Moderate
3 = Severe
4) SHARP
0 = None
1 = Mild
2 = Moderate
3 = Severe
5) CRAMPING
0 = None
1 = Mild
2 = Moderate
3 = Severe
6) GNAWING
0 = None
1 = Mild
2 = Moderate
3 = Severe
7) HOT-BURNING
0 = None
1 = Mild
2 = Moderate
3 = Severe
8) ACHING
0 = None
1 = Mild
2 = Moderate
3 = Severe
9) HEAVY
0 = None
1 = Mild
2 = Moderate
3 = Severe
10) TENDER
0 = None
1 = Mild
2 = Moderate
3 = Severe
11) SPLITTING
0 = None
1 = Mild
2 = Moderate
3 = Severe
12) TIRING-EXHAUSTING
0 = None
1 = Mild
2 = Moderate
3 = Severe
13) SICKENING
0 = None
1 = Mild
2 = Moderate
3 = Severe
14) FEARFUL
0 = None
1 = Mild
2 = Moderate
3 = Severe
15) PUNISHING-CRUEL
0 = None
1 = Mild
2 = Moderate
3 = Severe
SECTION TWO: Rate Your Present Pain
On a Scale of 0 to 100: (0 is slight and 100 is excruciating) which number describes your pain right NOW.
SECTION THREE: Describing Your Present Pain
Please check ONE descriptor that best describes your pain right NOW.
No Pain
Mild
Discomforting
Distressing
Horrible
Exruciating
SECTION FOUR: General Statement of Your Pain
Which word best describes your pain in general. Please select just one.
Brief
Intermittent
Continuous
SECTION FIVE: Your Pain over a 24 Hour Period
The following questions refer to your symptoms for a typical twenty-four hour period during the past two weeks. Please check only one answer to each question:
SEVERITY SCALE: 0=None/Never; 1=Mild; 2=Moderate; 3=Severe; 4=Very Severe
1) How severe is the hand or wrist pain that you have at night?
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
2) How often did hand or wrist pain wake you up during a typical night in the past two weeks (times/night)?
0 times
1 time
2 times
3 times
4 times
5 times
more than 5
3) Do you typically have pain in your hand or wrist during the daytime?
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
5 = Constant
4) How often do you have hand or wrist pain during the daytime (times/day)?
0 times
1 time
2 times
3 times
4 times
5 or constant
5) How long, on average, does an episode of pain last during the daytime (minutes)?
Less than 10 minutes
Between 10 - 60 minutes
More than 60 minutes
Constant
6) Do you have numbness (loss of sensation) in your hand?
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
7) Do you have weakness in your hand or wrist?
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
8) Do you have tingling sensations in your hand?
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
9) How severe is numbness (loss of sensation) or tingling at night?
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
10) How often did hand numbness or tingling wake you up during a typical night during the past two weeks?
0 times
1 time
2 times
3 times
4 times
5 times
more than 5
11) Do you have difficulty with the grasping and use of small objects such as keys or pens?
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
SECTION SIX: Your Pain in Relation to Tasks
SEVERITY SCALE: 0=None/Never; 1=Mild; 2=Moderate; 3=Severe; 4=Very Severe
1) Writing
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
2) Buttoning clothes
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
3) Holding a book while reading
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
4) Gripping a telephone handle
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
5) Opening jars
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
6) Household chores
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
7) Carrying grocery bags
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe 3
8) Bathing and dressing
0 = None/Never
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
Thank you! That was the last question. Please click submit.